Patient Care Coordinator (Registered Nurse)

Job Type

Full Time




3200 Chouteau Ave.
St Louis
United States



Casa de Salud (Casa) delivers high quality clinical and mental health services for uninsured and underinsured patients, focusing on new immigrants and refugees who encounter barriers to accessing other sources of care. Casa’s vision is to combine low-cost access to treatment with a focus on long-term prevention that results in better health and lower costs. Casa is unique in that it is the only organization in the metro area that offers the new immigrant community low-cost access while also acting as a portal to other services through our collaboration with numerous health and social service organizations throughout the metro St. Louis area.

The GUIA (Guides for Understanding Information and Access) Program is the team of case managers that provides health education, self-care management, and patient advocacy services at Casa de Salud. Our case managers work with individual patients to overcome barriers to health care by setting up appointments, attending those appointments with patients, ensuring follow-up care is scheduled and assisting with the financial aid process as needed. The GUIA Program team also promotes prevention through education and home visits that provide crucial information about the factors that lead to a healthy life. As part of our holistic view of health, GUIA also works to create systemic change in our region, making St. Louis a more welcoming place for the uninsured and immigrant communities.


The Patient Care Coordinator is a registered nurse who, as part of the GUIA program, uses his or her clinical knowledge to ensure Casa patients achieve timely, high-quality continuity of care beyond Casa’s walls. This includes active participation in the GUIA case management model for patients requiring care in the broader St. Louis health system, as well as supporting patients in establishing the necessary self-management behaviors needed to manage a chronic illness and promote wellness.


  • Works with the Program Coordinator and Lead Nurse to systematically ensure patient care at Casa is well-coordinated after on-site visits
  • Provides clinical perspective for the GUIA Team (which includes consulting on other case managers’ cases when clinical knowledge is needed, and facilitating communication with internal and external medical providers)
  • Enrolls patients seen in Casa’s clinic with a new or uncontrolled chronic illness in the Care Coordination registry (most commonly hypertension or Type 2 diabetes), and contacts these patients at regular intervals to assess their knowledge, motivation, and ability to manage their health, providing additional resources and information when needed
  • Provides case management for medically complex patients with the direction of the Program Coordinator
  • Orients and supports volunteer nurses who provide care to Casa’s patients through the Home Visit Program
  • In collaboration with the Community Health Worker, identifies and invites eligible patients to participate in the Home Visit Program
  • Audits no-show appointments to ensure proper patient contact/correspondence is completed and personally follows up with patients who are in urgent need of care


Provide Goal-Oriented Case Management

  • Empowers patients by working with them to identify barriers to care and solutions
  • Promotes health education through home visits for patients with complex situations
  • Makes referrals for patients to outside agencies for their health care needs
  • Accompanies patients to appointments to increase their level of comfort in the health care setting
  • Provides advocacy by assisting with applications for financial aid
  • Guides patients through obtaining supporting documentation for their care
  • Makes sure follow up appointments are arranged
  • Requests records for continuity of care
  • Documents in Casa’s electronic medical record in a timely, professional, and accurate manner

Work with the GUIA Team

  • Attends weekly GUIA Program meetings and monthly staff meetings
  • Collaborates with and supports other team members as necessary to ensure high-quality, seamless care
  • Provides “on-call” services, joining other Case Managers in readiness to go with a patient to the ER or see them for an urgent financial aid appointment
  • Attends any trainings as assigned by the GUIA Program Coordinator and participates in the implementation of GUIA initiatives
  • Promotes health literacy in the community and the clinic

Other duties as assigned


▪ Active Missouri RN license required; BSN preferred

▪ Oral and written Spanish and English fluency required

▪ Experience in case management preferred

▪ Commitment to working with medically underserved patient populations

▪ Strong interpersonal skills and ability to communicate effectively with organizational leadership, Casa medical providers, patients from diverse backgrounds, and colleagues from within and outside the organization

▪ Strong, collaborative problem solving skills

▪ Ability to handle high work volume, prioritize urgent issues, and remain focused on full scope of tasks

▪ Good fit with a dynamic and growing nonprofit organization

▪ Working knowledge of Microsoft Word and Excel

▪ Experience with electronic medical record documentation preferred, and ability to learn to use Casa’s electronic medical record required.

Working Conditions

▪ Work is performed in a typical clinic and office environment, as well as health care facilities, patient homes and other locations

▪ Occasional evening and weekend activities

▪ Individual means of transportation required to attend appointments all around the St Louis Metro area

▪ Average physical effort with some handling of light weights such as supplies or materials on an infrequent basis (10-15 pounds)

Benefits: This position is full-time. Full-time Casa employees are eligible for vacation, personal, and holiday benefits.

Level of Language Proficiency

▪ Oral and written Spanish and English fluency required

Professional Level


Minimum Education Required

4-year degree

How To Apply


Casa de Salud considers qualified applicants for employment without regard to age, race, color, religion, sex, national origin, sexual orientation, disability, or veteran status.

Open until filled; First reviews begin immediately.

Interested applicants should send cover letter, resume and salary history to Jorge Riopedre, President & CEO, or 3200 Chouteau Ave. St. Louis, MO 63103.